Thursday, Oct 20 2011
• 11 a.m. (ET)

Paul Starr: “Remedy and Reaction”

Health care has been one of the most contentious issues of President Obama’s time in office. Democrats view the passage of the Affordable Care Act as his finest hour. But Republicans are determined to repeal it. For most of the twentieth century Americans debated whether health care should be a right of citizenship. To understand why the issue is still such a flashpoint, we go back to the debate’s origins with Pulitzer Prize winning author, Paul Starr. In his latest book he examines America’s unique struggle with health care, and explains why we have become trapped in a costly and complicated system.

Guests

Paul Starr
professor of sociology and public affairs, Princeton University; co-founder and editor, "The American Prospect"; and author of "The Social Transformation of American Medicine."

Transcript

11:06:55

MS. DIANE REHMThanks for joining us, I'm Diane Rehm. Premiums for family health coverage increased by 87 percent from 2000 to 2006. Household incomes, at the same time, decreased by three percent. Here in the studio, Paul Starr. He's author of "Remedy and Reaction: The Peculiar American Struggle over Health Care Reform." He joins us to explain why we cannot afford not to reform our health care system.

11:07:40

MS. DIANE REHMThat's quite a series of negatives. Paul Starr is professor of sociology and public affairs at Princeton University, co-founder and editor of The American Prospect and author of an earlier book "The Social Transformation of American Medicine." We are going to take your calls, 800-433-8850. Send us your e-mail to drshow@wamu.org, joins us on Facebook or Twitter. Professor Starr, how good to see you.

11:08:24

PROFESSOR PAUL STARROh, thank you very much, Diane, for having me back on your show.

11:08:26

REHMNice to have you here. So America clearly has the costliest health care system in the country.

11:08:37

STARRIn the world.

11:08:37

REHMHow come -- in the world, forgive me. And how come we don't have the system to deliver the best medicine?

11:08:50

STARRThe United States is remarkable in how much it spends on health care. It's also remarkable for the wide disparity that exists between those who are fortunate to have good health insurance and good health care and those who are excluded. This book began with a puzzle. Why is it that the United States is still fighting over an issue that is more or less resolved in every other major democracy? We're still fighting over the principal of whether there should be public financing for health costs.

11:09:28

REHMAnd why is that?

11:09:31

STARRWell, I think the story has two parts to it. The first has to do with how the United States got off the track of development that most other countries followed in the first half of the 20th century when they instituted general systems for financing health care. Sort of the way we instituted a system to pay for education, for primary and secondary education. But we never figured out that in the first half of the 20th century.

11:09:58

STARRInstead what we did was enact a series of partial programs, a tax subsidy for private insurance, the Medicare and Medicaid programs, the Veterans health care system. And what happened is that we did a series of things that tremendously enriched the health care industry. We satisfied a majority of the public. We buried a lot of the cost. People don’t see the full cost of what they pay.

11:10:27

STARRAnd the result is, we got into, what I call, a policy trap by satisfying so many people and yet leaving so many problems. The system became more complicated, became more costly. When I first became interested in these issues in the early 1970s, Richard Nixon was the President. If you remember, Nixon had a proposal for comprehensive health insurance. Ted Kennedy had another proposal.

11:10:57

STARRWell, there were differences. But the assumption, at that time, was that we could resolve this problem on a bipartisan basis. And instead, decade by decade the problems have gotten worse and the battles have become more rancorous then they were. It is the story of, really, a tragedy of American politics and public policy.

11:11:19

REHMYou know, you take this story back to President Truman and his approval of programs for hospital construction, for medical research but nothing for helping people pay their medical bills.

11:11:39

STARROh, well President Truman did want to have a national health insurance program, he got defeated. That was a big turning point. There had been earlier efforts going back to the period around World War I, also efforts during the new deal, during the 1930s. But the Truman -- President Truman's effort was a major turning point because it set off a huge ideological battle in which the opponents did -- what they had also done in the '30s and earlier, and that is to portray this proposal for public financing of health care. As socialized medicine...

11:12:14

REHMRight.

11:12:15

STARR...associated with it the Soviet Union, they associated this idea with enemy regimes. And contrasted it with what was to be the American way, the voluntary way. And that voluntary system, Blue Cross, and so forth, was growing at the time. And it did insure a lot of people. And, you know, there was a hope that it could eventually insure everybody.

11:12:38

STARRBut the health insurance market never worked out that way. The health insurance market really wasn't a market where people who were sick, people who had chronic diseases, older people, so forth, could do very well. The Medicare program was partly a response for that.

11:12:54

STARRBut the way Medicare was set up, initially, if anything, I think, exacerbated the cost problem. We went through a period of spiraling inflation in the following decades. And increasingly many people came to regard the problem as unsolvable and that is really, I think, what is tragic about this.

11:13:14

REHMYou know, we -- it's fascinating to me that each White House, going back to John F. Kennedy and Lyndon Johnson, have tried to do something with a sector. I can remember following Joseph Califano around when he was talking about rising hospital cost, bringing down hospital costs. So each White House has somehow focused on one portion of it until now when President Obama comes in with his Affordable Care Act. And yet you say he made a huge mistake.

11:14:05

STARRWell, I think, several mistakes were made. But before we get to the mistakes, I just want to give the President credit. He put a tremendous amount of effort behind passing the program. In the end -- actually, at the beginning, he stood back, he let Congress take the lead. He did a lot of things, I think, that showed a great deal of political intelligence.

11:14:28

STARRAnd I think there's a great deal of wisdom in much of the law. But I do think some mistakes were made in the law and we can get to those. I think, one of the -- what may turn out to be the most serious mistakes has to do with the very slow time table for carrying it out. It stretches to 2014, it may well be possible for a new president elected in 2012, along with a new Congress, to repeal the major provisions of the law that, I think, could very well happen.

11:15:03

STARRAnd I think a mistake was made with the mandate and we can talk about that, the individual mandate. I do believe it's constitutional. I think it should stand up but it may not. It may get overturned and it could've been avoided. The law didn't actually need to have the mandate in the way that it's set up and that may also turn out to have been a mistake in the decision.

11:15:25

REHMHow could he have avoided that mandate that has become so controversial?

11:15:33

STARRHow could he have avoided it? Several alternatives. So let's think about why the mandate is necessary. The mandate is necessary because if you provide an insurance system that says your covered for your preexisting conditions, then -- and you do nothing else, then the rational thing for a healthy person to do is not to buy insurance until you get sick.

11:15:56

STARRYou know, but if you have an insurance system that, in effect, lets people take out insurance in the ambulance on the way to the hospital, it's not going to work. You have to healthy people paying in, not just sick people. So that's the basic problem. You need to prevent opportunism. But there's more than one way to do that. And we can actually look abroad and see how some other countries have dealt with this problem.

11:16:18

STARROne way that you can avoid this problem is to have rising -- if you don't sign up at the initial open enrollment, then you're going to pay a higher premium. And the way that can be set up is to recoup the money that you should've paid into the system when you were healthy. So you can do it without a mandate. You can do it with some kind of penalty, after the fact. I proposed another way to do this.

11:16:45

STARRI was trying, during the debate, to interest people in Congress and the White House in the alternative, and it's partly because I went on shows, on radio shows, call-in shows. And I heard a lot of angry callers. I remember one woman calling in and saying if they're going to require me to have health insurance, they might as well take me to jail because I can't afford it.

11:17:07

STARRAnd I might say to that woman, but there are going to be subsidies in the program. And it was clear she just didn't believe the subsidies were enough. So I realized that there's going to be a lot of skepticism out there, why not provide people with an opt-out, a no penalty opt-out? But if you opt-out, under my proposal, you can't opt back in whenever you want. You'd be opting out for a full five years, I proposed.

11:17:34

STARRWhat that means is that you wouldn't be able to get the subsidies and you wouldn't be able to get insurance with no preexisting condition exclusions. You could buy some other kind of insurance but you wouldn't get what's called the guaranteed issues under this program.

11:17:49

STARRSo this was a way to provide a safety valve for people who didn't like it and I think the President and members of Congress could've said, hey, look, if you don't like this program, just sign the opt-out and you're out of it." But I couldn't, unfortunately, interest anyone in that.

11:18:03

REHMBut the other thing that came through on the telephone certainly was I want government to stay out of my private life.

11:18:15

STARRWell, that would make a lot of sense if government wasn't already...

11:18:19

REHMExactly.

11:18:19

STARR...very involved. Really, if you add up all the government spending on health care, it comes to -- depends on how you do the calculations, but between 50 and 60 percent of total spending. And Medicare, Medicaid, the VA system, a lot of the American people are already getting health care with government help.

11:18:41

REHMPaul Starr of Princeton University. His new book is titled "Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform."

11:20:04

REHMAnd we have many listener calls on the line, Tweets, messages on Facebook. Here's the first treat -- Tweet treat which says, "Why does the U.S. have the most expensive health care in the world? Easy answer, greed." And here is a listener e-mail who says, "Let the courts invalidate the Affordable Health Care Act then let's do the simple thing that should've been done in the first place, Medicare for all. There's no room in health care for any for-profit insurance." How do you react to that?

11:20:53

STARRWell, I understand that view very well, but millions of Americans are satisfied with the insurance that they have. What the Democrats recognized going into this reform effort was that it wouldn't make any sense to overturn all these settled arrangements at once. There would be tremendous dislocation from trying to do that.

11:21:25

STARRIt made much more sense to try to take the additional steps that would be necessary to provide coverage to the uninsured, to begin to create a new system for controlling health care costs. But without disturbing and alarming and setting off reactions from the people who were satisfied with the insurance that they have.

11:21:52

STARRSo it's a tough call because many of those people were alarmed and have reacted negatively just the same, even though most of them will not see any loss of coverage.

11:22:04

REHMProfessor Starr, you mentioned other countries. Let's talk about Sweden, let's talk about Switzerland, how they have managed their health care system.

11:22:17

STARROther countries have very diverse systems. It's not true that in other countries there's always just a single governmental insurance system. Great Britain has a national house service, that's true. But you mentioned Switzerland, the Netherlands. Those are countries that do have private insurers. They have ways of regulating those private insurers. They often have national negotiations that's set at certain limits and payment rates.

11:22:48

STARRSo they create a much higher level of standardization, of rules in the system. One of the things that's so striking about the United States is that our system isn't only more costly. It's also more bureaucratic. The people who don't want a government program don’t understand that a government program could actually reduce the complexity of the system. Could -- but right now, there are countless numbers of different insurance plans, each with their own rules, each with their own paperwork. And the result is just a huge amount of work.

11:23:28

STARRAmerican doctors, for example, spend four times the amount on overhead as Canadian doctors. You know, that's the result of the genius of the American health care system that's produced this bureaucratic mess. But we can do better and I think other countries have done better in this respect.

11:23:47

REHMThe closest you said that we ever got to a bipartisan workout of a health care system for all was under President Nixon. What happened?

11:24:03

STARRSo President Nixon, after he was reelected in 1972, wanted to propose a health insurance program that would help bolster his popularity. And I think that became especially important to him during the Watergate crisis. It was a time when there were other proposals in congress, not just Senator Kennedy's but other proposals from Representative Wilbur Mills who was the Chairman of the Ways and Means Committee in the House and various others in the Senate. There was a deal to be made very, very clearly. Senator Kennedy was willing to be part of that deal.

11:24:40

STARRWhat happened in 1973, '74 is really a tragic tale. If Nixon, I think, had only been wounded by Watergate instead of being destroyed by Watergate we might well have had a national health insurance bill that year in '74. It came very close. The sides were willing to bargain. There was room to make a deal. But Nixon was destroyed. Wilbur Mills' career ended up being destroyed that year, too.

11:25:16

REHMWith -- yeah.

11:25:17

STARRThe personal fortunes -- the political moment was lost. And, you know, that's sometimes crucial. Now, I emphasize in "Remedy and Reaction" long historical forces that are at work. But I recognize there are moments when history can turn. It can turn one way or another, depending on leadership. And that moment in the early '70s was lost because of a failure of leadership, a national crisis that resulted in the collapse of the presidency.

11:25:48

STARRNow, in a way, you know, you could say we have the opposite story in 2009, 2010. Political leadership did see it through. They brought legislation to fruition over tremendous odds. So again, leadership can make a difference despite all these big forces that I talk about in (unintelligible) .

11:26:05

REHMSo leadership can make a difference, did make a difference. The Affordable Care Act did go through and yet you have this huge fight continuing. Not only in the court, but every day turn on any conservative talk show host who says, this is socialist medicine. It's got to be thrown out completely.

11:26:32

STARRSo the irony of that is that the proposal that got passed is really descended from a line of Republican ideas. The idea of a health insurance exchange with private insurance, which is the core initiative under the Affordable Care Act, that was an idea that the Heritage Foundation had helped develop. It was the basis of Governor Romney's reforms in Massachusetts. That plan in Massachusetts also included an individual mandate.

11:27:06

STARRThere was a great deal of hope among reformers of people who have been long working on this issue. A great deal of hope in 2006, 2007, 2008, with that model in Massachusetts maybe we could finally get a bipartisan compromise. After all if Romney had worked it out with the Democrats in Massachusetts, maybe we could find a way to do that at the national level.

11:27:30

STARRSo this was an idea that really came with a lot of a conservative pedigree behind it. And there was, I think, good reason to believe there could be Republican support for it.

11:27:43

REHMSo what happened?

11:27:45

STARRWhat happened, I think -- first of all, we have to go back to what happened in 1993, '94 when President Clinton proposed a reform. Initially many Republicans offered a counter proposal. Senator John Chaffey along with Senator Dole, at that time the majority leader, had a bill, which by the way included an individual mandate. At that time in the early '90s the Democrats favored an employer mandate. The Republicans an individual mandate. That's the way it was explained at that time.

11:28:19

STARRBut during '93, '94 something happened. The -- among some Republicans, the view developed that it would be better not to cooperate at all with President Clinton. Not to strike any kind of a deal, to bring down the whole effort. And that's what happened. And in the 1994 election Republicans did very well. The public blamed the Democrats who had raised their hopes, who said they were going to accomplish great things and had failed. And that disappointment underlined the Democratic Party. Republicans didn't suffer for having just opposed it, not having entered into a bargain.

11:28:58

STARRI think that experience had a big affect on what happened in 2009, 2010. Many Republicans wanted frankly to see the same thing happen. They wanted to see the president and the democrats fail. They wanted to reap the benefits in 2010 and they did.

11:29:15

REHMSo you believe that this whole health care issue is now totally political as opposed to with a real understanding of concerns.

11:29:31

STARRIt has become a completely partisan issue, which it was not 30, 40 years ago. And that is something, of course, that's happened to a lot of issues in this country. I mean, just think about the question of global warming and the environment. There was a fair amount of moderate Republican support for climate legislation several years ago. Now there's none at all.

11:29:55

STARRAnd what we've seen is deeply polarized political climate affecting one issue after another, making it extremely difficult for there to be any kind of middle ground. And I think if somebody looks at this story fairly -- I try to go through the whole history in this book "Remedy and Reaction." The Democrats in 2009 were trying to find a middle ground and they found no partner.

11:30:23

REHMAll right. We're going to open the phones, 800-433--8850. First to Arlene in New York City. Good morning to you.

11:30:36

ARLENEYes, good morning, Diane. And thank you for taking my call.

11:30:39

REHMSurely.

11:30:40

ARLENEWe talk about all these details about health care and we're really talking around the periphery of what I think is the core problem. And I had a front row seat at NYU Medical Center in the early (unintelligible) .

11:30:54

REHMArlene, you keep fading on us.

11:30:58

ARLENEOkay. At that time, in 1982, the large insurance companies demutualized and became public and went on Wall Street. Then we are trading our health care on Wall Street and that is an inherent conflict of interest because you cannot be beholding to investors and to the people who pay the premiums at the same time.

11:31:26

STARRWell, there certainly has been a tremendous change in the character of the health care system from what was overwhelmingly a nonprofit hospital and insurance system in the mid 20th Century to one that has increasingly become commercialized and for-profit. And I agree with you that a lot of our problems are the result of it. The whole industry of hospitals and other providers has become oriented toward reimbursement, maximization, sort of extracting the maximum amount of revenue that they can out of the system. And that, I think, has helped to drive up costs. But look, that's where we are.

11:32:08

REHMPaul Starr of Princeton University. He's winner of the Pulitzer Prize. His newest book titled "Remedy and Reaction." And you're listening to "The Diane Rehm Show." And now it's time to go to Arlington, Va. Good morning, Jo, you're on the air.

11:32:31

JOHi. Thanks for taking my call.

11:32:33

REHMSurely.

11:32:35

JOFirst, I wanted to profoundly thank Professor Starr for his book in '84. It was a crucial, crucial component of my dissertation and I'm forever grateful. Two comments. One is, I think I hear some discussion about health care cost reform. But I'd like to hear more about how controlling costs is really totally dependent on reforming practice to bring the evidence about effective and cost effective care into alignment with, you know, how do we control costs. And I'd like to ask, what do you see, Dr. Starr, about the role specifically of nurse practitioners in both controlling costs and reforming practice? And I ask this because I'm a nurse midwife. And I'll take your answer off the phone.

11:33:41

REHMAll right. Thank you, Jo.

11:33:43

STARROkay. So our caller had several different questions there. First, in general she's saying that we need to focus more on cost containment. And she raised the issue of using data about clinical effectiveness. And I have to tell you, I have been just incredibly discouraged by the response -- for example, by Newt Gingrich and others to the recent analysis by a federal commission of the data on the test for prostate cancer. And this was not an evaluation of cost effectiveness. This was just an evaluation of whether or not that test, in the end, produces any benefit at all, whether on net there is a saving of lives and the reduction of suffering.

11:34:44

STARRAnd I think many people just have difficulty in following statistical analysis. Yeah, some people do benefit but it turns out that many more people suffer adverse consequences as a result of these tests with false positives that lead to surgery, that have a certain rate of complications including death. This is a case where the evidence now is in favor of discontinuing the insurance payment. And yet we can't get consensus that when the evidence is that way we should follow the evidence.

11:35:28

STARRWe need to listen to the evidence. We need to pay attention to what scientists have to say. And we need to be able to say, in some cases, no we're no longer going to do that.

11:35:38

REHMShe also talked about the role of the nurse practitioner in controlling costs.

11:35:44

STARRYes. Well, one of the other problems that we face in the health care system is that physicians have gained a tremendous amount through specialization. We have a relative shortage of primary care. Nurse practitioners can make a great contribution to relieving that shortage.

11:36:04

REHMAnd they are making that contribution.

11:36:06

STARRYes.

11:36:08

REHMBut are they always accepted by the doctors in their role as nurse practitioner?

11:36:16

STARRThere's a long running conflict right now especially over the use of the title doctor for nurses who get a PhD.

11:36:23

REHMReally.

11:36:25

STARRYes.

11:36:25

11:36:31

STARR...to be called -- yes, yes.

11:36:33

REHMWhat's your view on that?

11:36:36

STARRWell, I could see where it would create some confusion in the minds of patients. But -- and honestly when -- on call-in shows like this some people address me as Dr. Starr, I'm a little uncomfortable. They might think I was a physician. I've sometimes gotten calls asking about back pain.

11:36:56

REHMSure.

11:36:57

STARRI don't know anything about that.

11:36:58

REHMAbsolutely, which is why I specifically wanted to address you as professor. And Paul Starr is professor of sociology and public affairs at Princeton University. He won the Pulitzer Prize for his book "The Social Transformation of American Medicine." His new book is titled "Remedy and Reaction: The Peculiar American Struggle over Health Care Reform." When we come back we'll take more of your calls, comments. I look forward to hearing from you.

11:40:03

REHMAnd welcome back. Here's an e-mail from one listener who says, "I find it very insulting that members of Congress have their health care paid for by citizens. The U.S. military members have government assistant healthcare, yet, reducing or doing away with Medicare, calling universal health care socialist. It seems to me," this caller says, "that Congress and the military have socialist health care." What do you think of that?

11:40:46

STARRWell, that is almost true. It's true that in the military and the VA we have government provided health care. That is government health care in the true sense. Actually, they do a pretty good job of it. The members of Congress agreed in this legislation to come under the Affordable Care Act. They will, under the law, get coverage through one of these new health insurance exchanges.

11:41:14

STARRAnd I think that was very important for them to, kind of, put their own fate on the line and agree that they would be part of this initiative. So, you know, they're, you know, whether that happens, whether the law is sustained is another question. I -- you know, it may not survive.

11:41:35

REHMNow, to Cleveland, Ohio, good morning, Lewis.

11:41:40

LEWISGood morning. I had a comment and a question.

11:41:43

REHMSure.

11:41:44

LEWISMr. Starr's first book begins with a wonderful line as to why all this happened. The dream of reason did not take power into account. It's probably one of the best lines for a book ever.

11:41:55

STARRThank you.

11:41:57

LEWISAnd Mr. Starr goes on to explain all the components that created this mess that we're in. The second is a question for Mr. Starr. For the folks who -- in your ideal plan, who want to opt out for five years, what happens if they go ahead and get in an accident or need health care? Does the government then jump in and take care of those folks, as it does now?

11:42:16

STARROkay, that's an excellent question. What I have said is, first of all, that people who decided to opt out of this program could still buy insurance. They'd, in effect, be opting into the world that exists now. That is you buy insurance, but it wouldn't cover pre-existing conditions. Now, suppose they got in an accident.

11:42:37

STARRAnd you're saying if they're brought to the hospital and they need emergency care; well, look, I believe it would immoral to turn down people who were injured in an accident and not to provide them medical care. So I'm not suggesting they be denied all care in an emergency. We also do have a law in this country that dates from 1986 that does provide a right to emergency care.

11:43:04

STARRAnd it's the only general right to health care that Americans have. It's one of the things, by the way, that distinguishes health care from any other service or commodity. It's one of the reasons, I think, why there's a good argument that health care is different from any other commodity. Many people have argued against the mandate on the grounds that, well, if Congress can create a mandate for health insurance, then why can't it require people to buy other products, as well.

11:43:33

STARRAnd some people have said why can't Congress require people to buy a plasma television or something like that. Well, there's no existing law that says you have a right to emergency plasma medical -- a plasma TV in case your favorite sports team is in the playoffs.

11:43:54

REHMThanks for calling, Lewis. Here's an e-mail from -- no, it's a posting on Facebook from Andrew who writes, "The government works on roads, bridges, power, water to ensure society can function. Why isn't the health of our workforce factored into that equation? Why are humans treated as expendable and replaceable resources?"

11:44:28

STARRThat is an argument that has long been made for a general system of financing healthcare. And, really, it's an argument that has carried a great deal of weight in other countries. I think many Americans believe that it was socialists who enacted universal health care in Europe. Well, that's actually not true. These were mostly conservative governments, sometimes liberal governments, who were responding to challenges from socialists and others.

11:44:57

STARRBut who were also responding to what they saw as the logic of providing health care and improving the health of the workforce, often improving the health of their military. They saw this as a national interest -- as a national security interest to have a healthy population, you know, but that argument just hasn't been able to win the day in the United States.

11:45:19

REHMSo how did we end up with a system of coverage so dependent on private employer-based insurance with separate programs for the elderly and the poor?

11:45:36

STARRHow did we end up, well, because to go back to the defeat of the national health insurance proposal of President Truman and then the defeat of the alternatives during the Nixon years; those general solutions got turned down and so different groups sought protection for themselves. And unionized workers and other workers got protection from their employers, veterans had their system, the elderly got some protection, each group satisfying it's immediate needs and very strongly defending the particular form of health care that has, but millions were left out.

11:46:20

REHMTo Jacksonville, Fla., good morning, Don.

11:46:25

DONGood morning. I will definitely be getting this book. I am 61 and on Social Security disability, but I have to wait two years for Medicare coverage and I've pretty well exhausted my resources. And paying a mortgage on top of that is -- it's getting really tight. Do you have any suggestions?

11:46:49

STARRYou know, in a couple of years you will be eligible for Medicare. In a couple of years the Affordable Care Act should go into effect and would provide you substantial benefits. And let me just explain how someone in -- is it, Don?

11:47:08

REHMYes, yes.

11:47:09

STARRIn Don's position would be affected. So, first of all, I assume that if you're on disability you've got a pre-existing condition.

11:47:17

DONOh, yeah.

11:47:18

STARRYeah, yeah, so under this law insurers cannot take a pre-existing condition into account. You have guaranteed issue and the price of health insurance does not reflect your individual health status. So health insurance becomes more affordable, even leaving Medicare aside. If you're going to be buying health insurance through this insurance exchange, you're going to be able to get it on much better terms than you would in the existing market.

11:47:50

STARRThat's the single biggest thing and, secondly, depending on your income, there is a subsidy. And the subsidy is designed to make insurance affordable. It's designed to keep the premium within a certain proportion of your income -- that might be eight percent, nine percent. It depends exactly what your income is, but it's the subsidy is set so that premium for the insurance will not exceed that percentage of your income.

11:48:16

REHMBut let's face it, Professor Starr, if, in fact, this is not scheduled to go into effect until 2014, if President Obama does not win re-election in 2012, the whole program could be thrown out.

11:48:38

STARRThat is entirely possible. That is certainly possible. I don't deny that.

11:48:45

REHMSo that people like Don...

11:48:47

STARRYes.

11:48:48

REHM...are going to be thrown back on what?

11:48:54

STARRWell, I don't know what kind of insurance Don has at the moment. Yeah, I should also mention Don, I think, is from Florida. The governor of Florida is not interested in implementing this law at all. So there's another problem there down in Florida. And, you know, it's -- I think it's tragic that the law wasn't put into effect more quickly.

11:49:18

STARRI think there were alternatives that would have enabled us to do that. I think if we had set up what's called a national exchange instead of a state-based exchange we could have also moved a lot more quickly in getting this done. You know, when Medicare was enacted in 1965, it was put into effect in just about one year. The Affordable Care Act enacted in 2010 doesn't go into effect until 2014.

11:49:42

STARRWhat is it that over these years has made it so difficult for us to implement laws more rapidly?

11:49:49

REHMAnd, of course, that remains the big question. Paul Starr is winner of the Pulitzer Prize. He's professor of sociology and public affairs at Princeton University. His brand new book is titled, "Remedy and Reaction: The Peculiar American Struggle over Health Care Reform." And you're listening to "The Diane Rehm Show." And now to Bowling Green, Ohio, good morning, Bob, thanks for joining us.

11:50:29

BOBGood morning. My original point has already been well covered that trying to mix health insurance with the profit motive has been a failure -- a 50-year failure now. So I'd like to raise another -- or ask a question. The professor said that the American people are happy with the health insurance they have now. He's talking to very different people than I. Everybody I know is enormously concerned with the ever rising costs of health insurance.

11:50:56

BOBI also believe -- I can't prove, but I believe that the reason a public option was so vigorously fought against was that the insurance companies realized that if the American people have the opportunity for a non-profit mode of health insurance they would flock to it in droves.

11:51:15

STARRActually, the law does provide for non-profit plans to be offered in every exchange -- national non-profit plans to be offered in every exchange. It's not the public option as it was originally conceived that is a federal government run insurance plan, but it is a non-profit plan that will be in every exchange. So let me just make that point.

11:51:37

STARRYou know, it's not that I think people are happy with their insurance. It's that the opponents of change repeatedly, over the years, have been able to frighten people with the idea that this reform, whatever the reform is going to be, is going to take away your existing insurance. And we went through that in the early '90s when the Clinton plan was on the table.

11:52:07

STARRAnd from that experience, I think, many democrats said, Okay, let's not fight that battle over again. Let's allow people to keep the insurance they have if they like it. That's basically -- you may have heard Barack Obama say that during the 2008 campaign. So it was an attempt to just avoid some of the pitfalls of the past.

11:52:32

REHMAnd to Oklahoma City, good morning, Troy.

11:52:37

TROYGood morning, Diane. I just would like to make a few comments and get the professor's ideas on them.

11:52:46

REHMSure.

11:52:46

TROYFirst, it seems to me that, although this has been polarized as a partisan ideal, it seems more libertarian versus communitarian and the idea of the mandate, the everyone must opt in or have some form of insurance, they're kind of missing the point. And no one's really explaining that, you know, through adverse selection that would bring the prices down and ensuring that there is plenty of money there to fund it. And I'll take the professor's ideas offline.

11:53:24

STARROkay, so just in case other listeners didn't get that term adverse selection. Let's explain what that's about. That's the idea that if you have a purely voluntary system, many healthy people are not going to bother to pay for insurance. The people most likely to buy insurance are the people who feel they're going to have high health care costs and they're more likely to be sick.

11:53:46

STARRSo that's the problem with adverse selection. And the idea of the mandate was to require everybody to come in then you spread the costs over the entire community. That's both the sick and the healthy and that's how you get the costs down. That was the basic philosophy of the mandate. And, you know, as the caller said, that is a kind of communitarian idea.

11:54:07

STARRActually, when Mitt Romney was governor of Massachusetts and he called for an individual mandate, he said it was the ultimate conservative principle of individual responsibility that every individual would be responsible -- would pay into the system if they could afford it. I'm putting him almost verbatim. So you could see this as communitarian, but you could also see it as individualist. In a way, you're holding individuals accountable, making them participate.

11:54:33

STARRSo you can look at it in different ways. I think that, you know, as I was saying earlier, we could have had an opt out. Perhaps if the politics works out there will be an opt out at some point, but I understand, also, why a lot of people are just offended by the idea that they'd be required to pay for insurance.

11:54:55

REHMBut, you know, it would seem that younger people would say why should I? Why should I spend my precious resources now because they're not worried about being hit by a car as they walk across the street?

11:55:13

STARRYeah, so, actually, the law has a special form of insurance for young invincibles, that's the term that's used.

11:55:20

REHMYoung invincibles.

11:55:20

STARRThe young invincible, people who don't, you know, young people who don't believe they're going to get sick. And that's a very low cost form of insurance with a very high deductible. And it would be there only in the case when you did get hit by a car, when you did have skiing accident or something, yeah.

11:55:38

REHMSam is calling from Revere, Mass. He says that under the Romney plan it does not reduce cost. It just keeps the insurance private and that what we need is a non-fee-for-service model.

11:55:57

STARROkay, well, there is a lot of change still going on in Massachusetts, legislation pending there to change the payment system. You know, what Massachusetts did was to take a step in bringing everybody in through a system that's gotten all but, you know, maybe two percent of the population insured. Massachusetts has dealt with a big problem that the rest of the country has not yet overcome.

11:56:19

STARRBut the cost problem is a serious one and what is really encouraging is that the state is now moving on to address those issues much more seriously. And, I think, it's going to be just as important an innovator in cost containment as it has been in universal coverage.

11:56:35

REHMPaul Starr of Princeton University his new book is titled, "Remedy and Reaction: The Peculiar American Struggle over Health Care Reform." Thank you so much for joining me.

11:56:51

STARRThank you, Diane.

11:56:52

REHMThanks for listening, all. I'm Diane Rehm.

11:56:55

ANNOUNCER"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Susan Nabors, Denise Couture, Monique Nazareth, Lisa Dunn and Nikki Jecks. The engineer is Aaron Stamper. A.C. Valdez answers the phones. Visit drshow.org for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information. Our e-mail address is drshow@wamu.org and we are on Facebook and Twitter. This program comes to you from American University in Washington. This is NPR.

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